I wanted to write to you to acknowledge the intense media interest we have been experiencing over the past few weeks. I apologise for the length of this update, but believe it important to share my thoughts with you all.
Firstly, I want to thank you all for your immense and outstanding efforts on behalf of Southern DHB. It is challenging to be under this level of scrutiny, and I know it takes a toll on all involved regardless of our roles and responsibility. The concerns raised are all very important issues. Over years this organisation has failed to take actions to address many significant issues and we now find ourselves in the position of having huge challenges which at times can seem insurmountable. Many of the challenges have been shared in various forums, however there are a few which are currently being discussed broadly in the media which I would like to update you all on.
One, unfortunately, could be forgiven for believing that things are all negative if reading the formal media. However, this is not the case. I encourage you to take time to go to the Southern DHB Facebook page, read the Southern Future e-newsletter and the Better Health supplements in community newspapers – and simply look around at all your colleagues around you – to remind yourselves of the outstanding stories and people who make a difference to our patients and communities every day.
This is not to say that there are not real challenges facing us. There are. And just as they have not surfaced overnight, they won’t necessarily be quick fixes to address. But I can promise you that I, the Commissioner team, and all of the executive leadership team, and I believe everyone else who comes to work each day at Southern DHB, are absolutely committed to addressing our shared challenges and putting Southern DHB in the best position to deliver the health services our community deserves.
Part of this is committing to working collegially and collaboratively across the whole of system, in line with our organisational values. These include being open about the issues we face (whether positive or negative), and taking positive action in our collective approach to resolving issues that are impacting on the care we wish to deliver to our patients or clients.
I did want to update you on a few of the specific areas that have been canvassed in the recent media coverage:
Surgical Waiting Times
This has been a matter of considerable concern at Southern, and the subject of focus at all levels of the organisation. On the surface our overall access rates appear reasonable. We excel in some areas and we are falling behind in others. Standardised intervention rates are one measure, but not the sole measure. I have had many people debate with me about the appropriateness of using such a measure, an often quoted statement is that these fail to take account of private insurance (inferring that in Southern we have below average insurance coverage rates and as such our population will be accessing lower private surgery). Equally, national intervention rates simply state what the “average” New Zealander is accessing. While it is standardised to adjust for demographics such as age, sex, ethnicity etc, it still only reports average. As a DHB we should not be striving to be average, but rather we should be aiming to constantly improve access. This said, we need to prioritise our effort on the areas which have lower access rates and to this extent this means some services may have to accept that we will need to prioritise our focus. Equally, as a DHB we have the responsibility to each and every person who resides with us. Presently access is variable with the former Otago and Southland DHB catchments having different levels of access (in some services Otago has better access and others Southland). We must take steps to ensure that you receive fair access regardless of where you live in our DHB.
Increasing the availability of theatre space is central to this challenge, and we are limited by the number of physical theatres we have to operate in. This is being tackled on multiple fronts. This year we have implemented the extension to theatre days, and added an acute Sunday list to alleviate the pressure during the week. We also need to ensure we are maximising the throughput that is possible within our existing space, and I am mindful of Sapere’s report that has compared our productivity with other DHBs and suggested we have opportunities to improve in this area. This has led to productivity initiatives including rolling out The Productive Operating Theatre (TPOT) to gain efficiencies in the perioperative space, and a significant production planning exercise. We are always open to further ideas and solutions not yet considered.
Surgeries have also been taking place at Mercy on an opportunistic basis, and we are in discussions around how we may be able to make greater use of the capacity they will gain as a result of the redevelopments underway at that facility.
Statements have been made in the media that we have employed Surgeons and have not necessarily provided them with adequate theatre time to allow them to operate on patients. Unfortunately this is indeed the case in some services. This goes back over many years and I am at a loss to understand how this practice has been allowed to occur. The same unfortunately has been the case with other resources. For example, as we have employed additional medical specialists we have not necessarily matched this with resourcing in other areas such as nurse specialist roles, allied health, and even clinical administration. How we respond to these challenges is significant. We can highlight all of the deficiencies of the past, or we can collectively work together to resolve the challenges and improve the services.
The state of the urology service has been the subject of media attention over the last week. There are major issues. The service is largely operating as two separate services between Dunedin and Invercargill, processes and practices across the service are variable, and there is concern as to whether we have invested adequately in the service in recent years. Overall intervention rates in Urology indicate that we are providing this service at around the national intervention rate levels. However there are significant numbers of patient referrals we have accepted and are failing to see within the expected timeframes. There are also a number of patients awaiting significant surgical procedures, for whom we are falling short of meeting their expectations.
We have commissioned an external review of our urology services as a response to staff concerns about resourcing levels, and wider DHB concerns around the performance of this service. When this is available, this will be shared with the wider organisation, and the community, given the high level of interest in this, and the opportunities to learn from the experience. It is likely that the review will identify some issues which will potentially make us more uncomfortable regardless of who you may be. As Chief Executive I have committed to being open about the review results and will be holding us all to account to address the issues. If this challenges us then we will be challenged together. Ultimately, our community deserves this.
We agree that greater collaboration and engagement is the only solution to the challenges the DHB faces. This is why investing in organisational culture has been such a high priority for Southern DHB. We appreciate the participation of all those involved in the external review of the urology service, as well as in the many other initiatives aimed at reducing wait times and improving experiences and outcomes for patients across the DHB.
Cardiac Surgery and ICU beds
You will have heard of the cases of cardiac patients whose surgeries have been postponed due to the shortage of ICU beds being available for their recovery. For both cardiac and cardiology services we have amongst the highest intervention rates in the country (some of this may well be related to the lower levels of private insurance creating greater demands on the public health system). This said, there remains patients who have been identified as needing cardiac surgery who are waiting longer than the maximum of 90 days which is deemed best practice.
We have been working with our cardiac and ICU teams to identify what we can do to improve the situation. Unfortunately, access to ICU beds is the single biggest rate-limiting factor.
We have worked progressively in recent years to increase capacity and resources in ICU/HDU. In 2013 we resourced 6 ICU and 6 HDU beds routinely and periodically stretched to up to 8 ICU and 8 HDU beds. Today there are 8 ICU and 8 HDU beds and we have recently approved extending the ICU resource to an extra ICU bed Tuesday to Saturday to try and support the delivery of the cardiac surgery needs. This extra bed will open just as soon as we are able to appoint the additional nursing staff signed off. While the extra bed will not be exclusively for cardiac surgery, its use will be weighted towards those patients. It will be staffed during the working week when the unit has both elective surgery and acute demand to meet.
The new ICU/HDU facility currently under development will increase this further to 8 ICU and 10 HDU beds that can be flexibly configured, meaning greater options for providing care. This investment is costing approximately $15 million of capital expenditure and we have increased operational resourcing significantly (a progressive increase in resourcing from last year through to when we open the new unit of approximately 80% increase in medical staffing and 40% in nursing by way of example). This is delivering us a significant improvement in the standard of care being able to be provided and a marked improvement in outcomes for patients. Ironically, however, this is placing greater pressure on the unit, as length of stay has increased placing greater pressure on bed availability.
The approved plans for the new unit is 18 resourced beds, but with space for 22 beds. I have asked for this to be reviewed given the improvements and as a part of the planning for 2018 we will be reviewing the extent of the resourced capacity recognising the unit will be opened in August 2018.
I also want to let you know that some of the media accounts on this matter may have given an inaccurate impression. This issue has been discussed with our Chief Medical Officer and the Clinical Leader for cardiac surgery, and although there have been postponements and delays for some patients requiring cardiac surgery in Southern, those who are at risk and need it urgently are receiving it promptly. There is no evidence to support the suggestion that patients are dying because their cardiac surgery is delayed by constraint in ICU beds. I do however acknowledge that the delays for elective surgery have resulted in some patients needing to be treated acutely which is unacceptable, and I am committed to improving this.
We are also in negotiations with Mercy to enable a more structured use of private capacity to de-escalate demand pressure as appropriate.
Bed pressure has been intense over the past couple of months, and we are expecting this to continue for the next few weeks until the winter pressure subsides. We have undertaken some initiatives opening some winter capacity, focusing on trying to reduce “stranded patients” or patients who are staying in hospital longer than needed due to a lack of care coordination and discharge planning, and in Dunedin we have approved the opening of a Medical Assessment Unit. In Southland we are working with WellSouth Primary Health Network to improve access to primary care as there are too many people accessing Emergency Department services instead of primary care.
We expected the Medical Assessment Unit to be open in August, but unfortunately the recruiting of resources to staff it has taken longer than we expected. This is now scheduled to be opened from 4 September. While this may miss the middle of winter pressure we remain committed to this as it will enable us to provide more timely care for those medical patients, depressurise the Emergency Department and enable us to be well prepared for the 2018 winter.
Recent comments in the media have heightened the issue of whether we need to open further capacity. This is particularly pertinent to the demand growth in Dunedin. We are expecting the Indicative Business Case for Dunedin Hospital to be supported within the next few weeks which will clarify the direction we are taking with respect to the redevelopment of Dunedin Hospital. With this understanding we will have a clear picture of the solution and timing for the long term. We will then immediately commence capacity planning for the intervening time period. Nothing will be out of scope for consideration. This will include the potential need to relocate some staff to make room for clinical space, it may also require us to continue to evolve the use of our Wakari campus as adding infrastructure on the Dunedin Hospital site is likely to be very problematic and as such we will have to be very strategic in our decisions. We will also be looking at how we use other providers and facilities across our district.
Making the changes needed to provide the best service to our people is not simple, and requires a whole of system approach based on the needs of our patients. It’s about keeping members of our community well, at home, well supported by primary care – so they don’t need to wait in ED, or spend days in hospital beds. This is not about alleviating pressure in the hospitals, but doing what is right for our people. It also means ensuring that when they arrive at hospital, they are seen in the most appropriate and holistic way, that achieves the best outcomes and makes best use of our resources.
This is why we have made and are continuing to make investments in areas we believe will enable a systemic, long term difference to how we provide care. These include:
- Primary and Community Strategy and Action Plan, to increase our efforts to provide more integrated care.
- Launching HealthOne, a shared patient records system, so health providers in the South Island can see important, life-saving information about our people, including conditions, test results, medications and any allergies they may have.
- HealthPathways, to ensure greater consistency and clarity in how conditions are managed in both primary and secondary care.
- Developing our telehealth services so patients can avoid travelling for some specialist appointments.
- Medical Assessment Unit – to provide a more comfortable, patient-centred facility to assess people with multiple medical conditions - particularly our older patients, enabling them to avoid long waits in ED.
- Improving our facilities. As well as the improvements to ICU and HDU noted above, our interim works will also see new gastroenterology facilities. We have already celebrated the opening of the new audiology unit at Wakari Hospital, a new education centre was opened in Southland, and the installation of a new MRI scanner in Dunedin. Plans are in place to refurbish and improve Lakes District Hospital in Queenstown. And of course, we have focused on the planning for the redevelopment of Dunedin Hospital, with the Indicative Business Case now completed awaiting Government’s approval which is expected imminently.
- Establishing a Community Health Council to ensure the voice of patients and the community remains at the centre of what we do.
- Developing leadership and a strong internal culture at Southern DHB. None of these challenges can be addressed by any individual, or only by clinical staff, or only by management. But with 4,500 of us pulling in a common direction, I genuinely believe we are capable of great things. I am committed to a culture that is kind, positive, open and values the strengths of our community. I ask for your engagement in the spirit of Southern Future, and all the small initiatives we can all undertake every day that moves us towards providing the best possible experience for our patients.
Please Talk to Us
There is much to discuss about all of these challenges and initiatives, and I want to give anyone the opportunity to discuss things directly with us. On Friday 11 August, you are welcome to a drop-in session in the Exec & SLT Meeting Room, 1st Floor Psychiatric Services Building, Dunedin Hospital from 1:30 to 5:00pm. You are welcome to come by, to discuss any of these issues, or others with myself, the Commissioner Kathy Grant, Chief Medical Officer Nigel Millar, the incoming Chief Nursing and Midwifery Officer Jane Wilson, and the Acting Executive Director Specialist Services Joy Farley. I am also very open to meeting with your team if you want me to come and meet in your work area (this may take a little time to coordinate diaries and times but I will do my best).
I will also be in Southland on Wednesday 23 August and a drop-in session will be held in Clinical Admin Meeting Room 2 from 1:00-3:30pm.
Finally, it is easy to be despondent when confronted with ongoing negative media, especially when we wish we could do more for those we serve. But I also know that daily we receive acknowledgements from patients and our community, genuinely grateful for the skill and care they have received from you all. Every one of our staff makes a difference, whether serving on the front lines of patient care, or behind the scenes to improve our systems, or in management positions, sometimes having to make challenging calls around how to direct our resources to have the greatest impact for those we serve. I believe wholeheartedly in the future of Southern DHB and thank you for your ongoing efforts – it is much appreciated.
Chief Executive Officer